Summary The small catamaran vessel WascaII departed her berth on Lake Wascana, Saskatchewan, to transport 16 school children and their supervisors to a picnic area on an island in the lake. Three of the children were in wheelchairs. Shortly after departure, as the vessel accelerated, it took on a marked trim by the bow, and the forward end of the passenger deck became submerged. The teachers instructed the passengers to move aft to reduce the trim. The vessel remained afloat and was beached some minutes later. All of the passengers were evacuated safely. Ce rapport est galement disponible en franais. Other Factual Information Description of the Vessel The basic layout of the WascaII vessel is shown in Figure1. Photo1. Photograph taken on the WascaII June 1999 The WascaII, a Starlighter catamaran-type small passenger vessel, consists of two cylindrical aluminum pontoons 450mm in diameter, 8.8m long, spanned by a wooden deck over welded frames and cross beams. Aluminum railings surround the perimeter of the passenger deck. Three rows of twin plastic seats, attached to aluminum footings on either side of the centre line, provide seating for 12passengers. The steering position and the control console are located at the port side forward, and the outboard motor is mounted at the stern. The vessel was bought from its original owners and licensed, on 05May1967, by the Wascana Centre Authority. Jean Vanier School Jean Vanier School provides educational services for children who are challenged physically and/or cognitively. School programs are designed to help students achieve their optimum level of emotional, social, intellectual, spiritual, and physical development. The Wascana Centre Act The Wascana Centre Authority (WCA) was established in1962 by an act of the Saskatchewan Legislature, The Wascana Centre Act. Wascana Lake Wascana Lake is an artificial body of water, centrally located in Regina (seeFigure2). The lake has a uniform depth of less than two metres and is used as a recreational resource for the public. Figure2. Sketch of the occurrence area, Wascana Lake Willow Island Willow Island is situated approximately 150m west of Wascana Park, approximately 550m from the Legislative Building, and has picnic and barbecue facilities. Access to the island is by catamaran from Willow Island Overlook. History of the Voyage The voyage was an end-of-school-year picnic to Willow Island on Wascana Lake on board the catamaran WascaII. The trip was organized jointly by the Jean Vanier School and the WCA on 14May2001. The group consisted of 26children with special needs, 17staff members, 2volunteers, and 4interns from the Saskatchewan Institute of Applied Sciences and Technology. Passengers were picked up at the Jean Vanier School by para-transit buses at around 1135 on 13June2001, and transported to the passenger landing at the Legislative Building. The boat operator started the day by placing safety equipment and other necessary gear on board. These items were normally removed from the boat at the end of the day and stored in a wooden locker ashore as there was no permanent storage space on the boat. Gasoline and lubricating oil were replenished in the outboard motor, and the vessel was taken to Willow Island, some 550m away, where the area was prepared for the picnic. The vessel was then taken to the Legislative Building landing to pick up the first load of passengers. As the WascaII was not large enough to carry all of the passengers at one time, several trips were planned. The first trip departed for the island at 1200 with two students in wheelchairs, two able-bodied students, four staff members, some equipment, and food. The weight of the food and equipment was estimated to be equivalent to that of two passengers. This trip was uneventful. For the second trip, three children in wheelchairs were embarked and positioned against the forward railing of the passenger area. Twelve more passengers occupied seats and one passenger stood at the after end of the boat. In all, there were 17people on board, including the operator, when the boat departed the dock at 1215. Winds were from the north-northeast at approximately 14knots with a slight chop on the lake. No pre-departure briefing was given to the passengers. A few feet away from the landing, as the vessel began to make headway, it started to trim rapidly by the bow. As it gained forward momentum, the forward part sank deeper into the water until the water reportedly reached waist level of passengers at the forward end of the passenger deck. The operator jumped overboard with the reported intention of reducing the weight at the forward end. No instruction was given to passengers to don personal flotation devices (PFD). Two of the teachers re-distributed the passengers on deck, allowing the vessel to return to a more level trim. One of the teachers then assumed control of the engine and steered and beached the WascaII at a location close to their original starting point. All children with special needs were then assisted ashore with the help of the teachers, bystanders, other school staff ashore, and the boat operator, who had swum back to shore. A bystander notified the local emergency services on the 9-1-1telephone system, and the regional fire department's water and ice rescue team arrived on the scene within five minutes. The students were taken into the emergency vehicles, examined, kept warm, and later transported back to their school. No injury was reported. The WascaII was manoeuvred to the tie-up area and withdrawn from service by the owner. Condition of Vessel on Recovery The superstructure of the catamaran was not damaged and the two pontoons remained intact. There was no pollution as a result of this occurrence. Vessel Inspection, Licensing, and Certification Shortly after being purchased by the owner, the WascaII was issued a Vessel Licence by the Customs Office in Regina on 05 May 1967. Pursuant to the Canada Shipping Act (CSA), the WascaII, as a vessel of less than 15gross tons that does not carry more than 12passengers, was exempt from inspection by Transport Canada Marine Safety (TCMS). However, the CSA requires that the owners ensure that such vessels comply with the provisions of related construction standards and safety and navigation equipment requirements.2 Small Vessel Safety Requirements Small Vessel Regulations (SVR) require vessels to be equipped with the following safety equipment: one standard lifejacket for each person on board; one approved lifebuoy with at least 9m of rope; one bailer and one manual pump; six pyrotechnic distress signals; one classBII fire extinguisher; and one anchor with at least 15m of cable, rope, or chain. The WascaII carried the required lifebuoy and 13PFD, manufactured to Canadian Government Standards Board (CGSB) standard CGSB65-GC-11. The lifebuoy did not meet the requirements for colour, retro-reflective tape, condition of cordage, or approval stamp. The vessel did not carry the required pyrotechnics, manual pump, or bailer. Standard lifejackets, unlike PFD, must meet rigid buoyancy standards and have the ability to turn an unconscious person to a face-up position in the water. However, PFD are more comfortable to wear. Construction Standards for Small Vessels SVR refer to the Construction Standards for Small Vessels (TP1332). These standards apply to small vessels, including commercial vessels and pleasure craft. They include hull construction and design requirements and are intended to convey to designers, builders, owners, and operators that it is their responsibility to carefully consider the intended operation of the vessel when determining construction, vessel freeboard, and stability. Passenger Loading and Vessel Stability Following the occurrence, the trim and stability of the vessel were examined by simulating the effects of passenger distribution on the platform deck. WCA employees participated in the simulation, which was limited to 12passengers, in accordance with the passenger seating installed. An initial draught survey of the unloaded vessel showed level trim, a mean midship draught of 159mm, a related lightship weight of 0.89tonnes, and a mean pontoon freeboard of 298mm. The total reserve buoyancy of the vessel when in this unloaded (lightship) condition was some 1.99tonnes. At the start of the simulation, the vessel was upright with six test passengers seated on either side of the deck and one in the port side operator seat. Passengers were moved singly from starboard to port to positions as far outboard as possible while standing between the seats. After four passengers were transferred, the port-side pontoon became submerged, and the test was curtailed. The elimination of any reserve righting ability, when the port-side pontoon became completely immersed, represented the limit of transverse stability and practical operation. Any increase in heeling moment caused by a further transfer of passengers would have led to the sudden capsize of the vessel. A loaded draught survey carried out with the operator and the 12test passengers seated symmetrically about the centre line showed a slight after trim of 40mm, a mean midship draught of 325mm, and a mean pontoon freeboard of 132mm. The total reserve buoyancy of the pontoons in this fully loaded condition was some 0.69tonnes, approximately 31.5percent of the loaded displacement. This reserve buoyancy is significantly lower than accepted design practice, which calls for a minimum safety margin of at least 100percent of the vessel's fully loaded displacement. To ensure that a satisfactory margin of safety of at least 100percent reserve buoyancy is maintained in the fully loaded condition, the pontoons are not to be immersed more than half of their depth. The dimensions of the intact pontoons and the vessel lightship weight are such that a maximum passenger capacity of eight persons, with a total weight of not more than 0.55tonnes, is not to be exceeded in order to maintain this safety margin. Interim Small Vessel Monitoring and Inspection Program Changes to the CSA led to the introduction of the Interim Small Vessel Monitoring and Inspection Program (ISVMIP), which initially came into effect in June1999, with the issue of Ship Safety Bulletin (SSB) No.11/99, which initially expired on 31December2000. Since then, it has been replaced with SSB No.04/20013, dated 26April2001, some five weeks prior to the occurrence; the program was extended to 31December2002. The ISVMIP is intended to assess the level of compliance of small vessels with existing regulations and to allow vessel owners and operators the opportunity to achieve phased-in compliance with regulations. The ISVMIP outlines safety requirements and the inspection regime, the Small Vessel Monitoring and Inspection Program (SVMIP), which requires a mandatory First Inspection and subsequent random inspections to achieve its safety objective. The program focuses on identifying vessels that may pose high safety risks and provides TCMS greater flexibility in delivering small vessel inspection services to the marine community. Vessels subject to the SVMIP are required to: have a First Inspection whereby they will receive a Notice of Survey; have an Annual Seaworthiness Information Report completed by the owner; be subject to Random Inspection and Compliance Monitoring by a Marine Safety Inspector, whereby a Letter of Compliance will be issued; and be approved by Marine Safety, if they are new, and are thus subject to inspection during construction. The owners of the WascaII did not receive SSB No.04/2001 and were not aware of the related SVMIP inspection requirements. Hull Maintenance The WascaII was maintained locally by WCA employees. Repairs that could not be effected by employees were contracted out to certified technicians. The closed pontoons were air-pressure tested annually for leaks, and leaks were fixed as and when necessary. A maintenance repair log was kept. At the time of the accident, the aluminum pontoons were intact. Personnel Certification and History The operator of the WascaII was not certificated, nor was she required to be so, as the vessel was 15gross tons and under and did not carry more than 12passengers. The operator at the time of the occurrence was a summer student hired as a guide by the WCA on 15May2001. One of the duties of a guide entails operating the catamaran. She had not previously operated a pleasure craft or any other marine craft and this was her first summer on the job. Standard Operating Procedures or Policies The WCA did not have formal documented standard operating procedures (SOP) in place for the operation of its vessels nor any written policy addressing the training of vessel operators. Training No formal training plan was in place for the operation of vessels by newly hired personnel, nor were written safety guidelines or instructions provided to cover issues such as: care of life-saving equipment and appliances; and emergency procedures and ship/shore communications with senior staff/management. Training or familiarization involved a three-hour on-the-job training session with newly-engaged personnel and formerly employed operators. The operator at the time of the occurrence was trained on the WascaII, the smaller of two vessels operated by the WCA. As a result, she chose this vessel for the school outing. Training or familiarization was hands-on and included the following: connecting the gas line to the outboard motor; checking the operation of the outboard motor; the storage of gasoline and safety equipment, both on board and ashore; procedures for donning a PFD; and procedures for securing the vessel at the end of the day. Some two hours were spent manoeuvring the vessel and making landings at different docks within the lake. Radio Communications During operational hours, the operator routinely kept in contact with the WCA front desk personnel via a two-way radio, which was fitted with a dial pad and could be used as a telephone to get in touch with personnel after working hours. However, unknown to senior management, the dial pad had not been operational for some time. Moreover, on the day of the occurrence, the boat operator had left the radio on Willow Island during her first trip, when she went to prepare the island for the picnic. Similar Occurrence in 1999 On 28 August 1999, the WascaII was being used to transport Regina Symphony Orchestra musicians to a moored barge in the middle of Wascana Lake when a similar incident occurred with 13persons, including an operator on board, during the Festival of Lights. The orchestra was to perform on the barge. Shortly after departure and while accelerating, the vessel began to trim by the forward end. At this time, speed was reduced, and the people on board adjusted their positions until the forward end of the vessel remained immersed approximately 600mm. The vessel then continued slowly to the barge, where the orchestra disembarked. The occurrence was not reported to any regulatory authority, and no investigation took place. Further, there is no record of remedial action having been taken by the WCA to enhance the safe operation of the vessel.